2016-11-03 Patient Care FHIR Call

Meeting Information

Patient Care FHIR Resources Conference Call Location: Conference Call Phone Number: +1 770-657-9270 Participant Passcode: 943377 WebEx: https://cerner.webex.com/cerner/j.php?MTID=mfc8969c4f77244480beee61d31385e79		Date: 2016-11-03 Time: 5-6:30pm ET
Facilitator	Michelle M Miller	Note taker(s)	Michelle M Miller
Attendee	Name	Affiliation
X	Elaine Ayres	NIH/Department of Clinical Research Informatics
X	Stephen Chu
	Danielle Friend	Epic
X	Eric Haas	Haas Consulting
X	Rob Hausam	Hausam Consulting LLC
	Laura Heermann-Langford	Intermountain Healthcare
X	Emma Jones	Allscripts
X	Mark Kramer	The MITRE Corporation
	Russ Leftwich	InterSystems
X	Tony Little	Optum 360
	Jay Lyle	Ockham Information Services LLC, VA
	Sarah Maulden	VA
	Hank Mayers	ReliaTech Consulting
	Jim McClay	Univ of Nebraska Medical Center
	Russell McDonell	Telstra Health
	Lloyd McKenzie	Gevity (HL7 Canada)
	Larry McKnight	Cerner
X	Michelle M Miller	Cerner
	Lisa Nelson	Life Over Time Solutions
	Viet Nguyen	Lockheed Martin, Systems Made Simple
	M'Lynda Owens	Cognosante
	Craig Parker	Intermountain Healthcare
	Scott Robertson	Kaiser Permanente
	Simon Sum	Academy of Nutrition and Dietetics
	Iona Thraen	Dept of Veterans Affairs
X	Bit Vo	Cerner
Quorum Requirements Met: yes

Agenda

Agenda Topics

1. Agenda review
2. Approve previous meeting minutes 2016-10-27_Patient_Care_FHIR_Call
   • Motion: Stephen/Elaine
3. Prior Action Item Follow-up
4. gForge change request

Supporting Information

STU 3 Timeline

From FHIR_Ballot_Prep

• Sun Oct. 9
  • Last date for change requests (subsequent change requests are auto-punted to release 4)
• Sun Nov. 20
  • All ballot reconciliation complete
• Sun Nov. 27
  • All substantive changes applied to Core
• Sun Dec. 4
  • Content freeze for ballot & connectathon & publication QA review
• Sun Dec. 24
  • QA review complete, Qa changes begin being applied
• Dec 29 - Jan 3ish
  • Publish

FHIR Maturity Levels

[1] Level 3 requires the artifact has been verified by the work group as meeting the DSTU_2_QA_guidelines and has been subject to a round of formal balloting; has at least 10 implementer comments recorded in the tracker drawn from at least 3 organizations resulting in at least one substantive change

Resource	Current FMM Level	Goal FMM Level	QA Status	QA Reviewer	Implementation	Comments
AllergyIntolerance	1	3		Michelle	Argonaut
Condition	2	3		Michelle	Argonaut
Procedure	1	3		Michelle	Argonaut
CarePlan	1	3		Michelle	Argonaut
Goal	1	3		Michelle
QuestionnaireResponse	2	2		Lloyd		Lloyd will QA to get to level 3
Questionnaire	0	2		Lloyd		Lloyd will QA to get to level 3
CareTeam	0	2	NA	Michelle		Aggressive goal (e.g. whether we'll get the implementations needed)
FamilyMemberHistory	1	2	NA	NA		Aggressive goal (e.g. whether we'll get the implementations needed)
ClinicalImpression	0	1	NA	NA
ReferralRequest	1	1	NA	NA
ProcedureRequest	1	1	NA	NA
Linkage	0	1	NA	NA
Flag	1	1	NA	NA
Communication	1	1	NA	NA
CommunicationRequest	1	1	NA	NA

Note: Bold denotes top 20 resource based on survey
Note: Contraindication and Risk Assessment are owned by CDS, not Patient Care

Minutes

Prior Action Item Follow-up

• Block Vote #2 (approved last week) had 29 gForges in it.
  • 10 were not persuasive / resolved - no change
  • 12 have been applied already (http://build.fhir.org/resourcelist.html)
  • 7 are not yet applied (6 non-substantive + 1 non-compatible)

gForge Change Requests

FHIR Publication / Backlog Status

• 85 unresolved tracker items (76 ballot + 9 high maturity resource non-ballot comments) to resolve by Nov 20
  • 37 scheduled in Block Vote 3 (Nov 3)
  • 7 scheduled in Block Vote 4 (Nov 10)
  • 18 requested input from vocab (value set related ballot comments)
  • 7 waiting for input
  • 5 waiting to be scheduled (joint with OO or in person requests)
  • 11 ready for discussion during our weekly conference call

Block Vote 3

Pulled from vote - but subsequently discussed and resolved individually

• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=8048 2015May core #1373 - Add communicaton-request as a code to the MessageEvents (Tim McNeil) Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11381 Expand CommunicationRequest.encounter to topic - 2016-09 core #539 (Paul Knapp) Persuasive with Mod
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11022 How is unknown different from absence of judgement? - 2016-09 core #41 (Jay Lyle) Persuasive with Mod

Pulled from vote - didn't have time to discuss today

• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11344 Allow CarePlan.activity.detail.performer to be CareTeam - 2016-09 core #502 (Emma Jones) Not Persuasive

Remaining Block Vote (today) Vote: Stephen/Elaine: 5 for - 0 against - 1 abstain

• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10468 New populate structures are broken (Lloyd McKenzie) Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10607 QA 2a: Add more goal examples to cover all contexts and elements (Michelle Miller) Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10617 QA 4e: consider adding unknown and other to CarePlan code element value sets (Michelle Miller) Persuasive with Mod
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10625 QA 4e: consider adding unknown to Procedure.status value set since minOccurs =1 (Michelle Miller) Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10642 QA 5c: Default value needed for AllergyIntolerance.status since minOccurs=0 and is-modifier element (Michelle Miller) Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10643 QA 5c: Default value needed for CarePlan.activity.detail.status since minOccurs=0 and is-modifier element (Michelle Miller) Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10999 Questionnaire.item.concept -> questionItemCode - 2016-09 sdc #65 (Stephen Chu) Persuasive with Mod
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11020 Need use-case for reaction.certainty - 2016-09 core #39 (Jay Lyle) Persuasive with Mod
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11023 Why isn't AllergyIntolerance.reaction an Observation? - 2016-09 core #42 (Jay Lyle) Not Persuasive with Mod
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11027 Scope of negation is unclear - 2016-09 core #46 (Jay Lyle) Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11051 Explain or remove Questionnaire datatype allowed for CarePlan.activity.detail.definition - 2016-09 core #70 (Dave Carlson) Not Persuasive with Mod
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11077 How does one assert that the subject does NOT have a condition? - 2016-09 core #96 (Galen Mulrooney) Persuasive with Mod
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11089 Inconsistencies between AllergyIntolerance and Condition - 2016-09 core #170 (Chris Moesel) Persuasive with Mod
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11090 Make performer consistent across Procedure & ProcedureRequest - 2016-09 core #171 (Chris Moesel) Not Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11134 Clarify linkId - 2016-09 core #288 (Daniel Rutz) Persuasive with Mod
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11151 Separate clinical status from clinical workflow status & align w/ Condition.status - 2016-09 core #305 (Stephen Chu) Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11153 lastOccurrence should be on reaction - 2016-09 core #307 (Stephen Chu) Not Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11154 AllergyIntolerance.onset and reaction.onset are duplicates - 2016-09 core #308 (Stephen Chu) Persuasive with Mod
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11163 Logically age is estimated property should be a child of age - 2016-09 core #317 (Stephen Chu) Not Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11168 Clarify ClinicalImpression.action - 2016-09 core #322 (Stephen Chu) Persuasive with Mod
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11170 Include "risk" as an element in the CarePlan structure Will accept this as suggested to be implemented as extension - 2016-09 core #324 (Stephen Chu) Not Persuasive with Mod
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11173 CarePlan needs support for reviews - 2016-09 core #327 (Stephen Chu) Not Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11176 Differentiate CareTeam.type and name - 2016-09 core #330 (Stephen Chu) Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11181 Will accept inclusion of "supporting clinical information" as extension to ProcedureRequest - 2016-09 core #335 (Stephen Chu) Persuasive with Mod
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11229 Why are SNOMED codes being used for Questionnaire.item.concept in example? - 2016-09 core #383 (Riki Merrick) Not Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11332 Acknowledge Advance Directives as type of Care Plan - 2016-09 core #490 (David Tao) Considered for Future Use
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11335 Allow multiple organizations for care plan - 2016-09 core #493 (David Tao) Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11343 Add CarePlan.definition - 2016-09 core #501 (Emma Jones) Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11347 CareTeam.type -> CareTeam.category - 2016-09 core #505 (Emma Jones) Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11379 Make Communication.topic choice of Reference and Identifier - 2016-09 core #537 (Paul Knapp) Not Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11473 Add more use-cases with List - 2016-09 core #637 (Lloyd McKenzie) Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11920 Required value set is missing "proposed" concept - 2016-09 daf #4 (Calvin Beebe) Persuasive with Mod
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=12291 QA: Fix badly chosen RxNorm code (Grahame Grieve) Persuasive

Block Vote #4 (Preview)

• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=9044 Need extension to track FHIR data type (Lloyd McKenzie) Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=9275 Questionnaire reference to Valueset is only by reference cannot link by URI as in elementdefinition (Brian Postlethwate) Not Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10481 QuestionnaireResponse should have only one recursion point for nested "item"s (Josh Mandel) Not Persuasive with Mod
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11000 enableWhen.question -> enableWhen.enablingQuestion - 2016-09 sdc #66 (Stephen Chu) Not Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=12064 Abatement needs to be simplified (David Pyke) Not Persuasive
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=12170 Clarification on Questionnaire item.repeats (Michele Mottini) Persuasive with Mod
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=12173 New Questionnaire extension to specify exclusive multiple-choice item (Michele Mottini) Persuasive

Discussion

AllergyIntolerance

• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=12136 Searching on optional attribute is dangerous (e.g., allergyintolerance.category)- Mark Kramer - resolved

In Person (Pending Schedule)

In Person Requests -- in the process of being scheduled

• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11281 Overall Condition.clinicalStatus and Condition.verificationStatus Condition body site - 2016-09 core #435 - Clem McDonald - TBD
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11290 clinical impression and condition - 2016-09 core #444 - Clem McDonald - TBD

Joint with OO -- in the process of being scheduled

• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11026 Relationship between Condition and Observation - 2016-09 core #45 (Jay Lyle)
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11119 Differentiate ProcedureRequest and DiagnosticRequest and align their elements - 2016-09 core #273 (Danielle Friend)

Feedback on prior resolutions - may need to revisit when Rob McClure can attend.

• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11354 - add extension for condition findings
  • Resolution is inconsistent -- a terminology service would still need to extract out the substance from the product codes
  • In some jurisdictions, like the UK, the use of the condition codes is very much in the 80% (closer to 100%)
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11352 - category cardinality
  • Do 80% of systems support multiple categories?
  • Our resolution conflicts with the FHIR GA guidelines 4e that say when constraining to the "code" data type, “ensure all codes are mutually exclusive or are defined in a proper hierarchy where siblings are mutually exclusive” – since the value set binding is required and cardinality is 0..*, the value set is neither mutually exclusive, nor defined in a proper hierarchy

Backlog - Ready to Discuss in Subsequent Calls

Resources with higher maturity - target FMM Level 3

AllergyIntolerance

• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11021 Increase cardinality of substance and make certainty relation to substance not reaction - 2016-09 core #40 (Jay Lyle)
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11025 Need to explicitly assert presence vs. absence of a risk - 2016-09 core #44 (Jay Lyle)
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11155 Unclear how the negation value set will work - 2016-09 core #309 (Stephen Chu)
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=12177 Review/expand the AllergyIntolerance.criticality valueset (Mohannad Hammadeh)

CarePlan / Goal

• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11116 Better define the careplan.activity.outcome field - discussion occurred during the CarePlan (Wed, Oct 26) conference call. PCWG agreed that outcome is needed on both the activity and goal. For example, a goal of losing 20 pounds might include activities to 1) reduce caloric intake via diet and 2)exercise 30 minutes per day. The outcome associated with the weight loss goal might be an observation with the updated body weight whereas the outcome on the activity side might be the number of calories burned via exercise or calories consumed via diet. Next steps:
  • expand/clarify the outcome definitions on both the activity and goal.
  • harmonize the outcome structure to allow the activity to reference an observation (like the goal outcome allows)
  • bind the outcome codeableconcepts to value sets
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=12090 Rename goal attribute
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11344 Allow CarePlan.activity.detail.performer to be CareTeam - 2016-09 core #502 (Emma Jones) -- pulled from block vote

Condition

• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10635 QA 5a: Resource references exist in both directions for Condition and ClinicalImpression (Michelle Miller)

Procedure

• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=11162 Suggest include reference to remedial treatment(s) - 2016-09 core #316 (Stephen Chu)

Questionnaire / QuestionnaireResponse

• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10998 Questionnaire.concept -> Questionnaire.code and update definitions - 2016-09 sdc #64 (Stephen Chu)
• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=12186 Proposed Changes to Questionnaire / Questionnaire Response from Tuesday evening discussion (Grahame Grieve)

Care Team

• DAF - http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10715 Add entered in error to valueset-daf-careteam-status (Michelle Miller) - related to http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10725, which is part of the Vocab set to review

ProcedureRequest

• http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=9335 Orders to not do things (Emma Jones)

Adjourn

Adjourned at 6:31pm Eastern.

Meeting Outcomes

Actions http://gforge.hl7.org/gf/project/fhir/tracker/?action=TrackerItemEdit&tracker_item_id=10662 Clarify how medical history should be handled - schedule joint discussion with SD Daniel Lanphear (submitter of gForge 8458) to draft new resource proposal for transfusion.

Next Meeting/Preliminary Agenda Items Agenda review Approve previous meeting minutes Motion: <moved>/<seconded> Abstain - <#>, Negative - <#>, Approve - <#> gForge change request

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